| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $87 | 0% | $87 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $206 | 0% | $206 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | 0% | $82 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $251 | 0% | $251 |
Medium |
| X-Ray - Four Images, Bitewings | $109 | 0% | $109 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
Medium |
